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Neuro Doctor, Neurologist (MD)

Category: Neurology

Satisfied Customers: 3828

Experience: American Board Certified Neurologist, Internal Medicine

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I recently saw my movement disorder neurologist about severe

Resolved Question:

I recently saw my movement disorder neurologist about severe Essential Tremors (which I'm learning other doctors don't take seriously). I know I should be thrilled that there is advancement in medicine that I can get deep brain stimulation and have an implant device inserted so my neurologist can adjust for my tremors. But I am scared of having someone operate on my brain! I already had a cholesteatoma removed from my right ear.Is the surgery considered risky at all?Also, can most neurologists help me? My movement disorder neurologist just had his HMO contract cancelled, and I really liked him. The other neurologist I saw before him also had a degree in psychiatry, so she just wanted me on more anti-depressants when I needed Inderal. I didn't realize neurology had subspecialties...thank you!

Regarding the surgery; the DBS (deep brain stimulation) surgery for ET (Essential Tremors) is FDA approved treatment and it is considered as effective and over all very safe too. Being a surgical procedure there are always some risks but see that this surgery has already been conducted on myriad number of patients and over all it is tolerated very well. You may go through the following official article about a recent study conducted to learn the safety and effectiveness of this surgical procedure and the result of this study is very encouraging and it is indeed found to be effective and safe;

http://www.ncbi.nlm.nih.gov/pubmed/19911883

Although surgery is an important option however see that before surgery you may try few different treatments and if everything else fails then only to try the surgery. Below I will provide a guideline and a list of varieties of treatment options for the control of ET and if you see any of these below options you have not yet tried then you may consider then first before considering the surgery.

Please find below the guidelines and the different treatment options of the control of ET;

First of all if there are any obvious triggers or provoking/exacerbating factors are present for these tremors they need to be avoided. Examples of such trigger factors for ET include;

5) Stress diluters like counseling/therapy (if stress is contributing to tremors). The above mentioned CAM & MBM too can help as stress diluters in some patients.

6) There are some additional special treatment options that are not routinely tried since some of them are still experimental but they may be considered because these do not involve surgeries so worth trying before undergoing surgery, and examples for such special treatments include;

Focused deep Ultrasound therapy

GKT (Gamma Knife Thalamotomy) etc

7) If all the above options fail then it is time to consider the surgical options and the following are the different surgical options tried;

DBS (Deep Brain Stimulation) of the thalamus

Surgical Thalamotomy etc

Between the above two surgical options the DBS is the preferred surgery since it is simpler, safer and also it is a reversible procedure so if for some reason you do not like this procedure, or if there are any complications etc they can easily pull the electrode out and terminate the procedure. But as pointed above overall this surgical procedure for ET is tolerated well and it is quite effective too.

If possible see a movement disorder neurologist, if that is not possible then seeing a general neurologist is fine too since most of the general neurologists are very familiar and comfortable in managing ET (essential tremors).

Please let me know if you have more questions. And if you feel you have received the information you are looking for rate me “Excellent” to compensate me for the time and effort put by me in answering your question.

Excellent response! thank you! I did rate you already!!May I just ask what the difference is between clonazepam and clozapine? I also tried some Parkinson's Disease medication called Requip...wow, really bad side effects.Also, my movement disorder neurologist insists that I take clonazepam on a regular basis as well as the Inderal before I try other medications as preventative maintenance to ward off any bad episodes (which I had in January and February when I was not taking on a regular basis). Apparently clonazepam is supposed to be more effective (according to him and the MayoClinic) because it reaches other brain chemistry that Ativan doesn't.But I've been told repeatedly by my psychiatrist (who writes the script of the clonazepam, not the neurologist) that if I take it daily, I will build up a tolerance and then the medication will never work again. Meanwhile, the neurologist wants me, as stated previously, to take it as a preventative medication like Remeron and Inderal on a daily basis.The clonazepam definitely helps, but I think if I did take regularly, it won't work anymore. What is your opinion?And I am taking the Remeron, although I'm not sure why that antidepressant is preferred over the others; I've been on a lot of websites about ET and they all definitely recommend Remeron?(The Remeron isn't helping with my depression over this condition, but then again I've tried other antidepressants and they don't work either with my depression.) I also read on the ET website that ultrasound, although already used in Europe but in clinical trials in the U.S., sounds promising, too.Thank you again for your detailed responses...it was scary before I knew what was going on as the tremors got worse. I thought I was having a panic attack that lasted for months!Could a panic attack last for months? I tried to hide the tremors from people at school (I'm a teacher), but that just made the tremors worse from trying to hide it. I can't stand the staring though from random people when I've had a bad day and need to get errands done. I feel like Katherine Hepburn. Thank you again!

Clonazepam comes under the group of benzodiazepines which are generally used for anxiety and stress or for sedation, and the clozapine comes under the group of neuroleptics which are mainly used for psychiatric disorders. But in your case these are recommended for the ET (essential tremors) since the experience shows that these meds help with the ET. Between the above two meds clozapine should not be tried initially, it is used only after trying few other meds because it can cause more serious side effects compared to other meds that are used for ET.

Parkinson’s meds like requip most often do not help for ET and produce lots of side effects too.

Yes it is true if meds like clonazepam is used daily for preventive purpose then it can build up tolerance but see that it is not must that everybody will experience the tolerance. And anyway clonazepam is generally not tried first unless you have lots of anxiety and stress, rather initially meds like inderal or primidone, topiramate etc are tried.

Remeron, the antidepressant is found to be helpful in some ET patients but not all. If it is not helping with the depression then you may need separate depression treatment. If remeron is not helping with the tremors then other options need to be explored. And there is no other antidepressant other than remeron that would benefit the ET otherwise you could have tried such antidepressants so that they help both with the depression and the tremors.

Yes the ultrasound option is still experimental in USA, hope it will be available soon. The advantage of this option is there are no side effects and it helps too so if this becomes routinely available in USA then it will help many ET patients and without much fear for the side effects.

Typical panic attacks are short lasting so if the attack persists for moths then it is less likely panic attack. But what happens is many patients with ET also may have some anxiety too so the combination of these both may make it look like panic attack but true panic attacks do not last that long.

I can fully understand your frustration because these tremors can be quite bothersome and disabling too in some patients, and also the social embarrassment because it is difficult to hide them but not to lose hopes as there are many options that are available as discussed earlier. If remeron is not helping then there is no point in continuing with it, you may try the clonazepam and if you do not develop tolerance you may continue it indefinitely. If you feel like developing the tolerance then it should be slowly tapered off and then other options need to be tried in place of clonazepam like inderal, topiramate etc - may be in combination since a single agent may not be sufficient for someone who seems to be having severe tremors like you. Primidone too is an option if not already tried. If these do not help then at that point in time you may need to explore the other options mentioned earlier like the special treatments if they are available (ultrasound etc), and then the DBS surgery may need to be considered too if none of the above help.

Please let me know if you have more questions. And if you feel you have received the information you are looking for rate me “Excellent” to compensate me for the time and effort put by me in answering your question.

I feel like you know more than the first neurologist I saw... yes, I am taking the Inderal 60mg x 3 and the clonazepam already. I am also taking 45 mg of Remeron for both depression (over this situation) and E.T., but it's not helping at all with the depression. I'm not quite sure if it's doing maintenance to prevent another E.T. spell yet, but I'd like to switch anti depressants. Any other antidepressants you could recommend?Thank you so much!

As I had mentioned earlier there is no other antidepressant other than remeron that can help with both depression and the ET together. If you feel remeron is not helping with the depression then you may try other options to manage the depression and I am not sure what else you had already tried, what I will do is provide a list of different options below to manage the depression, if you see any of the below options you still have not already tried then you may consider trying them;

This is the list of different treatment options for the management of depression;

F) If the above do not help then the following special or surgical interventions may be considered;

VNS (vagal nerve stimulator)

rTMS (Repetitive Transcranial magnetic stimulation)

ECT (electro convulsive therapy)

CES (Cranial Electrotherapy) etc

I feel you might have already tried many different treatments for the control of depression other than the remeron so if you see any treatment in the above list you already have tried please disregard it and you may consider the ones that are not yet tried in the above list.

Regarding the tremor management; as I had mentioned in my previous post you may try first different medications may be in combination if they are not helpful, then the special treatments, if they also do not help then the surgical options (DBS etc). I see that currently you are on Inderal and clonazepam; on Inderal there is still room and dose may be increased up to around 240 mg (total per day) provided you are not having any side effects, and on clonazepam (I am not sure on your current dose) the dose may go up to around 6 mg per day (in divided doses) provided there are no side effects. If these medications and their dosage adjustments do not help then you may try the other options as discussed earlier above and also in my previous posts.

You are welcome and please let me know if you have more questions. And if you feel you have received the information you are looking for rate me “Excellent” to compensate me for the time and effort put by me in answering your question.

Regarding the clonazepam, I can take up to 6mg per day but I try not to to avoid tolerance. The neurologist wants me to take it daily as preventative for anxiety, but the psychiatrist says not to...that once you build up tolerance you will never be able to take clonazepam again???? I don't know who to believe. thank you again!

Yes I agree with your point, clonazepam indeed can cause tolerance, and I did touch this issue in one of my previous posts too. Please see that I am just providing information, I am not advocating trying clonazepam - either on regular basis or in higher doses, I am just giving different options and different strategies to combat these severe tremors & anxiety but please do not try any of the above recommendations if you are not comfortable with it. I know of patients who have taken it on regular basis even at relatively higher doses but yet did not develop major tolerance so I was advising from my experience but since different people react to meds differently so there is no way to tell whether you will not develop or develop tolerance for a med beforehand. And if the tolerance developed you can always taper off the dose slowly and resume your previous regime (a small daily dose, or a preventive dose as needed basis). In managing health conditions there are different approaches because there are lots of individual variations so there are different ways of approaching the same thing and that will explain why your neurologist and psychiatrist expressing different views, both these views are valid and final decision has to be made on case to case basis. There are patients who try clonazepam of regular basis or at relatively higher doses but still do fine and there are some other who develop tolerance even for smaller doses. And again I am just giving you different options to consider and there is no right or wrong in these approaches because these are just different ways of approaching the management of a health condition. If you are not comfortable with regular usage of clonazepam or using it at higher doses then you may just leave it like that for now and please focus on other options discussed earlier for the management of the ET.

You are welcome and please let me know if you have more questions. And if you feel you have received the information you are looking for rate me “Excellent” to compensate me for the time and effort put by me in answering your question.

I will tell you that...the things you have to go through to be an Expert are quite rigorous.

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